Background: Chronic low back pain (cLBP) can interfere with daily activities, and individuals with elevated pain-related fear (also known as kinesiophobia or the fear of injury due to movement) can develop worse long-term disability. Graded exposure (GEXP) protocols use successive participation in avoided activities to help individuals overcome fearful movement appraisals and encourage activity. We sought to develop a series of GEXP virtual reality (VR) walking and reaching scenarios to increase the exposure and engagement of people with high kinesiophobia and cLBP. Objective: This study aims to (1) determine GEXP content validity of the VR application and (2) determine the feasibility of individuals with cLBP performing locomotion-enabled physical activities. Methods: We recruited 13 individuals with cLBP and high pain-related fear to experience six VR modules, which provide progressive movement exposure over three sessions in a 1 week period. At session 1, participants ranked each module by likelihood to avoid and assigned an expected pain and concern for harming their back rating to each module. Participants provided a rating of perceived exertion (RPE) after experiencing each module. To test feasibility, we administered the system usability scale (SUS) and treatment evaluation inventory (TEI) following the final session. In addition, we measured pain and pain-related fear at baseline and follow-up. Results: The 12 participants who completed the study period assigned higher avoidance (P=.002), expected pain (P=.002), and expected concern (P=.002) for session 3 modules compared with session 1 modules. RPE significantly increased from session 1 (mean 14.8, SD 2.3) to session 3 (mean 16.8, SD 2.2; P=.009). The VR application showed positive feasibility for individuals with cLBP through acceptable SUS (mean 76.7, SD 13.0) and TEI (mean 32.5, SD 4.9) scores. Neither pain (P=.20) nor pain-related fear (P=.58) changed significantly across sessions. Conclusions: The GEXP VR modules provided progressive exposure to physical challenges, and participants found the VR application acceptable and usable as a potential treatment option. Furthermore, the lack of significant change for pain and pain-related fear reflects that participants were able to complete the modules safely.

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Background: There has been a growing interest in the application of gamification (ie, the use of game elements) to computerized cognitive training. The introduction of targeted gamification features to such tasks may increase motivation and engagement as well as improve intervention effects. However, it is possible that game elements can also have adverse effects on cognitive training (eg, be a distraction), which can outweigh their potential motivational benefits. So far, little is known about the effectiveness of such applications. Objective: This study aims to conduct a systematic review and meta-analysis to investigate the effect of gamification on process outcomes (eg, motivation) and on changes in the training domain (eg, cognition), as well as to explore the role of potential moderators. Methods: We searched PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ProQuest Psychology, Web of Science, Scopus, PubMed, Science Direct, Excerpta Medica dataBASE, Institute of Electrical and Electronics Engineers Xplore, Association for Computing Machinery, and a range of gray-area literature databases. The searches included papers published between 2008 and 2018. Meta-analyses were performed using a random-effects model. Results: The systematic review identified 49 studies, of which 9 randomized controlled trials were included in the meta-analysis. The results of the review indicated that research in this context is still developing and lacks well-controlled empirical studies. Gamification in cognitive training is applied to a large range of age groups and audiences and is mostly delivered at a research site through computers. Rewards and feedback continue to dominate the gamification landscape, whereas social-oriented features (eg, competition) are underused. The meta-analyses showed that gamified training tasks were more motivating/engaging (Hedges g=0.72) and more demanding/difficult (Hedges g=–0.52) than non- or less-gamified tasks, whereas no effects on the training domain were found. Furthermore, no variables moderated the impact of gamified training tasks. However, meta-analytic findings were limited due to a small number of studies. Conclusions: Overall, this review provides an overview of the existing research in the domain and provides evidence for the effectiveness of gamification in improving motivation/engagement in the context of cognitive training. We discuss the shortcomings in the current literature and provide recommendations for future research.

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Background: Gamification has remarkable potential in the learning space. The process of creating a gamified system and its influence on human behavior reflect the interaction between educators and machines. Objective: The purpose of this pilot study was to present Ethoshunt as a gamification-based mobile app that can be used in teaching and learning ethics. Methods: This study involved a mixed-methods research design. The researchers surveyed 39 undergraduate students who were introduced to Ethoshunt in order to examine the relationships between mobile app usability and positive emotions, ethical competency, and user experience. Affinity diagramming was used as a tool to organize the opinions and experiences of participants using featured gamification elements. Results: Game dynamics and game mechanics explained the functionality of Ethoshunt. In addition, the learning flow through Ethoshunt was discussed. Overall, the findings were positive, and mobile app usability had the strongest relationship with positive emotions (r=0.744, P<.001), followed by ethical competency (r=0.686, P<.001) and user experience (r=0.614, P<.001). Conclusions: Positive emotions could be perceived as an important dimension in the development and usability of Ethoshunt. The researchers suggest that the gamification-based mobile app advocated in this study may provide ideas for ethics educators who wish to develop a technology-mediated learning environment.

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Background: Traditional methods of delivering Advanced Life Support (ALS) training and reaccreditation are resource-intensive and costly. Interactive simulations and gameplay using virtual reality (VR) technology can complement traditional training processes as a cost-effective, engaging, and flexible training tool. Objective: This exploratory study aimed to determine the specific user needs of clinicians engaging with a new interactive VR ALS simulation (ALS-SimVR) application to inform the ongoing development of such training platforms. Methods: Semistructured interviews were conducted with experienced clinicians (n=10, median age=40.9 years) following a single playthrough of the application. All clinicians have been directly involved in the delivery of ALS training in both clinical and educational settings (median years of ALS experience=12.4; all had minimal or no VR experience). Interviews were supplemented with an assessment of usability (using heuristic evaluation) and presence. Results: The ALS-SimVR training app was well received. Thematic analysis of the interviews revealed five main areas of user needs that can inform future design efforts for creating engaging VR training apps: affordances, agency, diverse input modalities, mental models, and advanced roles. Conclusions: This study was conducted to identify the needs of clinicians engaging with ALS-SimVR. However, our findings revealed broader design considerations that will be crucial in guiding future work in this area. Although aligning the training scenarios with accepted teaching algorithms is important, our findings reveal that improving user experience and engagement requires careful attention to technology-specific issues such as input modalities.

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Background: Many researchers have been evaluating how digital media may impact the emotional and perspective taking aspects of empathy in both clinical and nonclinical settings. Despite the growing interest in using virtual reality (VR) and VR games to motivate empathy, few studies have focused on empathy for people who live with chronic pain. Objective: Chronic pain affects, by conservative estimates, 1 in 5 people in industrialized countries. Despite this prevalence, public awareness of chronic pain was remarkably low until the recent opioid crisis; as a result, stigma remains a problem frequently faced by people who live with this condition. To address this, the VR game AS IF was developed to increase nonpatients’ empathy toward the growing number of people who live with long-term chronic pain. On the basis of our prior work, we overhauled our approach, designed and built a VR prototype and evaluated it, and offered design suggestions for future research. Methods: We introduced the design features of the VR game AS IF and described the study we devised to evaluate its effectiveness. We adopted a mixed methods approach and compared the empathy-related outcomes in both pre- and posttesting. A total of 19 participants were recruited. Results: The findings of this study suggest that the VR game was effective in improving implicit and explicit empathy as well as its emotional and perspective taking aspects. More specifically, for the Empathy Scale, the total pretest scores (mean 47.33, SD 4.24) and posttest scores (mean 59.22, SD 4.33) did not reach statistical significance (P=.08). However, we did find differences in the subscales. The kindness subscale showed a statistically significant increase in the posttest score (mean 15.61, SD 2.85) compared with the pretest score (mean 17.06, SD 2.65;P=.001). For the Willingness to Help Scale, a significant increase was observed from a t test analysis (P<.001) of scores before (mean 7.17, SD 2.28) and after (mean 8.33, SD 2.03) the gameplay. The effect size for this analysis was large (d=−1.063). Conclusions: The contributions of this research are as follows: AS IF provides a promising approach for designing VR games to motivate people’s empathy toward patients with chronic pain, the study evaluates the potential effectiveness of such a VR approach, and the general design suggestions devised from this study could shed light on future VR game systems.

This is the abstract only. Read the full text free (open access) on the JMIR Serious Games website. JMIR is the leading ehealth publisher: fast peer-review - open access - high impact.